I50.20 — Unspecified systolic (congestive) heart failure
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The patient's medical record must fully document medical necessity for the cardiac catheterization and support the diagnosis and procedures billed.
- Each claim must include ICD-10-CM diagnosis code(s) that accurately reflect the patient's condition and reason for the procedure and these codes must be linked to the CPT procedure codes on the claim.
- When a referring/ordering physician is required, the name and NPI of the referring/ordering physician must be reported on the claim; for extra-cardiac angiographic services the treating physician's name and NPI must be submitted in items 17/17a of CMS-1500 or electronic equivalent.
- For patients post-heart transplant without evidence of rejection, use primary diagnosis Z09 (follow-up after completed treatment) and secondary diagnosis Z94.1 (heart transplant status); add the underlying disorder code when coding I25.82 or I31.4.
Key Coverage Criteria
- Medicare Part B covers the professional component of cardiac catheterization and coronary angiography when performed in hospital inpatient and outpatient facility settings.
- Diagnostic cardiac catheterization performed in an office setting (where permitted) is covered under Medicare Part B for both professional and technical components.
- Global and technical component procedures are covered under Part B when performed under personal physician supervision in an IDTF, free-standing facility, physician office, or physician-directed clinic (physician present in room for entire procedure).
- Each dialysis session performed for an ESRD patient must be reported on a separate line for dates of service on or after 2007-04-01.
- When the hemodialysis prescription is three times per week and each session is furnished, bill each session as CPT 90999 with no modifier; these sessions will be paid as routine conventional dialysis.
- Dialysis sessions furnished in addition to three per week that have medical documentation supporting reasonable and necessary need should be billed as CPT 90999 with the KX modifier for consideration of additional payment.
20 Active Policies
L35490 — Category III Codes
J05
L37537 — Frequency of Hemodialysis
J05
A55703 — Billing and Coding: Frequency of Hemodialysis
J05
L39913 — Artificial Intelligence Enabled CT Based Quantitative Coronary Topography (AI-QCT)/Coronary Plaque Analysis (AI-CPA)
J05
A57552
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